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WORKERS Ok LIABILITY INSURANCE <br />POLICY <br />We have the right to recover our payments from anyone liable for an injury covered by this policy, We will not enforce our <br />right against the person or organization .named in the Schedule, (This agreement applies only to the extent that you <br />perform work under a written contract that requires you to obtain this agreement from us.) <br />This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. <br />Schedule <br />r I � � ,�,� � � � MM r, � MV ♦ IAM s it 1 <br />Per Poky MIn1muM Waiver Premium by State <br />$5007 AL, AR, CA, CO, GT, CSC 1177, IL, lN, 1A, KS, ME, MO. Mf, MS, MT, NV, NM, OH, OK, OR, PA, RI, SD, UT, VT, VA, VVA, wV <br />$25Q AK, DE, LA, NY <br />$100: NC <br />$50: wVl <br />NPA: AZ, PL, GA, Hl, MA,, MN, MO, NE, SC, TN, T <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated- <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 02/01/17 Policy No. 710170329 Endorsement No. 8 <br />Insured Rincon Consultants, inc Policy Effective Gate 02/01/17 <br />Insurance Company Star -Stone National Insurance Company <br />Countersigned By. a <br />WC 00 03 13 <br />(Ed. 4-84) <br />Copyright 1983 National Council on COMpensation Insurance. <br />